Transcript Nose and Paranasal Sinuses

Bakhshaee M, MD
Rhinologist
Assistant Professor of Mashad University of Medical Sciences

Four sessions:
1.
Anatomy, Physiology, and Immunology of the Nose, Paranasal Sinuses, and
Face
2.
History and Clinical Examination of the Nose; Tumors of the External Nose
and Face
3.
Malformations and common disorders of the Nose, Paranasal Sinuses, and
Face
4.
Inflammations of the External Nose, Nasal Cavity, and Facial Soft Tissues
Estimated time for each session is 100 min

Including:
Initial assessment: 10 min
Lesson delivery: 60 min
3. Discussion: 15 min
4. Question and problems of previous session:
10 min
5. A brief talking on next session: 5 min
1.
2.
Anatomy, Physiology, and Immunology of the Nose, Paranasal
Sinuses, and Face

Basic Anatomy of the Nose, Paranasal Sinuses, and Face

Morphology of the Nasal Mucosa

Basic Physiology and Immunology of the Nose
Facial Skin and Soft
Tissues
•The relaxed skin tension lines
(RSTLs):
Scars can be made less
conspicuous by taking these
tension lines into account
•The aesthetic units of the
face:
an important consideration in
the treatment larger soft-tissue
defects
The Facial Skeleton
Knowing the various
components of the bony facial
skeleton and their
relationship to one another
is important in trauma
management and also in
the diagnosis and treatment o
inflammatory diseases
of the facial skeleton and their
complications.
Nasal Cavities
Nasal Vestibule
Nasal Septum
Nasal Valve
Lateral nasal Wall
Choana
Lateral Nasal Wall
Bony Structure:
1.
2.
3.
4.
5.
Maxilla
Ethmoid
Palatine
Inferior Turbinate
Sphenoid
Functional apparatus:
1.
2.
3.
4.
Turbinate
Meatus
Sinus ostia
Nasolacrimal duct orifice
Nasal Cavities
Roof:
1.
2.
Cribriform palate
Ethmoid fovea
Floor:
Hard palate
1.
Maxilla (Ant)
2.
Palatine (Pos)
Paranasal Sinuses
Air-filled cavities that
communicate with the
nasal cavities
All but the sphenoid sinus are
present as outpunching of the
mucosa during embryonic life,
but except for the ethmoid air
cells, they do not develop into
bony cavities until after birth.
Maxillary Sinus

Medial:
Lateral nasal wall

Superior:
Orbital floor

Posterior:
Pterygopalatine fossa

Inferior:
Alveolar ridge ( root of
second premolar and first
molar)
Ethmoid air cells

Medial:
Middle turbinate

Superior:
Fovea ethmoidalis ( Ant
cranial fossa)

Posterior:
Sphenoid sinus

Lateral:
Lamina papyruses ( orbit)
Sphenoid Sinus

Inferior:
Nasopharynx

Superior:
Ant and middle cranial
fossa , Sellae tursica

Posterior:
Clivus and posterior
cranial fossa

Lateral:
Optic nerve
Internal carotid
Cavernous sinus
Frontal Sinus
Inferior:
Orbital roof
Posterior:
Anterior cranial fossa
Nerve Supply
Innervation
Anatomy
External
Muscular attachments
Ostiomeatal Unit
Morphology of the
Nasal Mucosa
Mucus:
Squamous epithelium
Respiratory Mucosa
Olfactory Mucosa
Respiratory Mucosa:
Epithelium
2.
Lamina Properia:
Venous erectile tissue
Nasal glands
Immunocompetent cells
1.
Olfactory Mucosa:
primary olfactory center
( olfactory bulb)
secondary olfactory center
(olfactory cortex)
tertiary olfactory centers
(including the hippocampus,
anterior insular region, and
reticular formation)
Nose is of major importance in conditioning
the air before it reaches the lower airways
Physical Principles of
Nasal Airflow
Nasal Air Flow
Laminar vs Turbulent
Nasal Cycle
Regulate by autonomic
nervous system
80% of human each 2 hours
Conditioning of the
Inspired Air
Humidification
Temperature regulation
Protective Functions
of the Nasal Mucosa
Nonspecific Defense
Mechanisms
1.
2.
3.
Mechanical defenses
(mucociliary apparatus)
Nonspecific protective
factors (Interferon,
Proteases, Protease
inhibitors , Lysozyme
Antioxidants)
Cellular defenses
(phagocytic cells)
Specific Immune
Responses
1.
2.
3.
4.
Humoral immune
response
Cellular immune response
The endothelial cells
The epithelial cells
Various organ systems are involved in the production of voice and speech:
Glottis,
 Supraglottic vocal tract,
 Central nervous system

must be coordinated in order to produce a normal voice sound

Hyponasal speech (rhinophonia clausa) : occurs when these segments
contribute less to sound production as a result of partial or complete nasal
obstruction or mass lesions in the nasopharynx

Hypernasal speech (rhinophonia aperta): develops when the nasopharynx
and nasal cavities over contribute to sound production.
cleft palate, velar palsy due to various causes

1.
2.
3.
4.

The human olfactory system consists of
Intranasal olfactory mucosa
Primary olfactory center
Secondary olfactory center
Tertiary olfactory center
The precise sequence of events that are involved in olfaction is still
uncertain.
1.
2.
3.
4.
5.
Name the main the nasal septum
structure.
Name the functions of the nose?
The major artery of the nose is ….
Sphenoid sinus is drained to ….
Orbital cellulitis is seen often due to …
sinus involvement.
History and Clinical Examination of the Nose; Tumors of the External
Nose and Face

Patients should be given an opportunity to
describe their complaints “in their own
words,”







Nasal obstruction
Discharge
Epistaxis
Specific allergy history
Headaches
Olfactory dysfunction
Facial pressure or pain

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Acute and chronic rhinitis (e.g., allergic, atrophic)
• Sinusitis
• Deviated septum (congenital, acquired)
• Nasal pyramid fracture
• Septal perforation
• Nasal polyps
• Cephalocele
• Adenoids
• Tumors of the nose, paranasal sinuses, and nasopharynx
• Foreign bodies (especially in small children)
• Drugs

Adverse effects: oral contraceptives, antihypertensive agents (e.g., reserpine,
propranolol, hydralazine), antidepressants (e.g., amitriptyline)

Drug abuse: e.g., oxymetazoline , phenylephrine

1.
2.
3.
4.

1.
2.
3.
4.
5.
Transport of odorants
Nasal obstruction Deviated septum,
mucosal
swelling, polyps, tumor
Scar tissue occluding the olfactory
groove
After intranasal surgery
Perception: damage to the
olfactory epithelium caused by:
Toxic substances SO2, NO, ozone,
Heavy metals, varnishes
Drugs
Viral infections Influenza
Radiotherapy (rare)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Stimulus conduction and processing
Avulsion of fila olfactoria Skull base
fracture
Aplasia of the olfactory bulb (rare)
Kallmann syndrome
Injury to olfactory centers
Contusion or hemorrhage due to head
injury
Neurodegenerative diseases
Alzheimer disease,
Parkinson disease,
Diabetes mellitus
Olfactory hallucinations after epileptic
seizures, in schizophrenia

1.
2.
3.
Inspection
Mouth breathing
Shape of the external nose
Skin changes such as erythema

Palpation
 Useful
for detecting bony discontinuities
 In patients with suspected neuralgias
Anterior
Rhinoscopy

To evaluate the nasal vestibule
and the anterior portions of the
nasal cavity

Posterior rhinoscopy was formerly done to evaluate
the nasopharynx and posterior nasal cavity
(choanae, posterior ends of the turbinates, posterior
margin of the vomer)

Endoscopy is commonly used to examine this
region
Nasal
Endoscopy

Nasal endoscopy has become the
most important and rewarding
clinical examination method in
rhinologic diagnosis
Nasopharynx

First the examiner advances the
endoscope into the nasopharynx
and inspects:




Eustachian tube orifice
Torus tubarius
Posterior pharyngeal wall
Roof of the nasopharynx
Ostiomeatal
unit

Nasal endoscopy is particularly
useful for evaluating the
ostiomeatal unit

Nasal Patency:
 Hold a reflective metal plate under the nose
 Holding a wisp of cotton in front of each
nostril
 Active anterior rhinomanometry
 Acoustic rhinometry

Skin Tests

The total immunoglobulin E (IgE) assay

Nasal provocation test

The total immunoglobulin E (IgE) assay

1.
2.
3.

Several types of test substance are used:
Pure odorants that stimulate only the olfactory nerve (coffee, cocoa,
vanilla, cinnamon, lavender)
Odorants with a trigeminal component (menthol, acetic acid,
formalin)
Substances that also have a taste component (chloroform, pyridine).
Patients with a complete loss of smell (anosmia) cannot perceive pure
odorants but can at least sense or taste the other substances.

Objective olfactory testing is far more costly
and is generally performed only at large
centers




Conventional Radiographs
Computed Tomography (CT)
Magnetic Resonance Imaging
Ultrasonography

Limited indication these days
Indications




Water projection
Caldwell
Acute inflammation
To evaluate midfacial fractures
WATERS
CALDWELL

If there is a high index of suspicion for
sphenoid sinus involvement, a lateral sinus
projection should be added to the study

The craniocaudal extent of the frontal and
maxillary sinuses can also be evaluated with
this technique

Indications
An occasional malformation,
 The main indications for CT scanning of the
nose and paranasal sinuses are
1. Chronic sinusitis
2. Trauma (especially frontobasal fractures)
3. Tumors


The normal mucosal lining of the sinuses is
not visualized.

The bony sinus walls appear hyperdense
(white)
Magnetic Resonance
Imaging
The strength of MRI
lies in its superior
soft-tissue
discrimination

Disorders that involve the paranasal sinuses in
addition to the cranial cavity or orbit (e.g., tumors
and congenital malformations such as
encephaloceles)

It can also supply information that is useful in
differentiating soft-tissue lesions within the
paranasal sinuses (mucocele, cyst, polyp)

It can distinguish between solid tumor tissue and
inflammatory perifocal reaction

Patients with electrically controlled devices
such as a cardiac pacemaker, insulin pump,
cytostatic pump, or cochlear implant.

Modern internal fixation materials such as
titanium are usually nonmagnetic and
therefore MRI-compatible

The paranasal sinuses can also be visualized
with ultrasound.

The sphenoid sinus is inaccessible to
ultrasound imaging because of its location.
Benign Tumors
1.
2.
Inverted
Papilloma
Osteomas

It is a locally aggressive tumor, and transformation
to squamous cell carcinoma is periodically described

Symptoms and diagnosis:

Nasal airway obstruction, headache, and occasional
epistaxis.
The lesion often has a polyp-like appearance when inspected
by nasal endoscopy


Treatment:

The treatment of choice is surgical removal

Benign bone tumors that may occur as isolated
masses, especially in the ethmoid cells and frontal
sinus

Symptoms and diagnosis:

Often they do not become symptomatic until they obstruct
drainage tracts to or from the paranasal sinuses, leading
secondarily to headaches and recurrent bouts of sinusitis

Treatment:

As soon as an osteoma becomes symptomatic, it should be
surgically removed

Malignant tumors of the nasal cavity and paranasal sinuses are far
more common than benign masses.

Histologically, the great majority (> 80%) are tumors of the epithelial
series (e.g., squamous cell carcinoma, adenocarcinoma, adenoid
cystic carcinoma).

Neoplasms of mesenchymal origin, such as osteosarcomas and
chondrosarcomas, as well as malignant lymphomas are much less
common.

Metastases from other malignancies are occasionally found, with the
primary tumor residing in the kidney, lung, breast, testis, or thyroid
gland.

The main sites of predilection are the nasal
cavity and maxillary sinus, followed by the
ethmoid cells, frontal sinus, and sphenoid
sinus.

Because many tumors originate in the
paranasal sinuses themselves, they often do
not produce clinical manifestations until they
have reached an advanced stage
Obstructed nasal breathing
 Bloody rhinorrhea
 Fetid nasal odor
 Swelling of the buccal soft tissues
 Swelling at the medial canthus
 Headache, facial pain, and
 Hypoesthesia or numbness of the cheek
 Orbital infiltration can lead to displacement of the orbital
contents, diplopia, or proptosis
 Trismous
 Epiphorea
 Dental loosening


Unilateral sinusitis that is refractory to
treatment

The clinical examination includes

Endoscopic inspection of the nasal cavity

Search for regional lymph-node metastases by bimanual
palpation of the cervical soft tissues.

Since sinus tumors are apt to invade the nasal cavity
secondarily, endoscopy alone may provide little
information on the extent of the mass. For this reason,
computed tomography and/or magnetic resonance
imaging should always be performed

is individualized according to the histology and extent of
the malignant tumor, and the treatment plan should be
coordinated with the radiotherapist and medical
oncologist.

Since the great majority of lesions are squamous cell
carcinomas, however, the treatment of choice will usually
consist of surgery and postoperative radiation

Since only about 20% of sinonasal malignancies
metastasize to regional lymph nodes, a neck dissection is
necessary only in patients who have clinically positive
cervical nodes

Many of these cases will require postoperative
radiotherapy

Is a rare neurogenic malignancy that arises from the
sensory cells of the olfactory region and generally occurs
in adults

Advanced, the tumor causes obstructed nasal breathing,
recurrent epistaxis, and particularly hyposmia or anosmia.

Some of these tumors become symptomatic only after
invading the cranial cavity or orbit, causing headache or
visual deterioration
Diagnosis
is based on endoscopy and
especially computed tomography or
magnetic resonance imaging; only
these modalities can accurately
define the tumor extent

Based on a combination of tumor resection and
postoperative radiotherapy
1.
2.
3.
4.
5.
Name five more common sinonasal
symptoms.
How you check the nasal patency?
What imaging modality is the best for
sinonasal evaluation?
Name the common symptoms and signs
of sinonasal tumor.
Which tumor is specific for the nasal
cavity?
Malformations of the Nose, Paranasal Sinuses,
and Face

Malformations involving the nose may be
caused by developmental abnormalities of
the nasal floor, palate, nasal roof, and
intranasal region
Incidence of one in 5000 to one in 10,000 births.
More often unilateral than bilateral.
The atresia is bony in 90% of cases and membranous in only 10%.

Bilateral choanal atresia is an acutely life
threatening emergency because the neonate,
except when crying, is an obligate nasal breather
until about the sixth week of life.

Cyanosis that is present at rest and improves with
exertion is called paradoxical cyanosis because of
its opposite pattern relative to cyanosis with a
cardiac cause

Unilateral choanal atresia may be manifested by a
purulent nasal discharge on the affected side.

Choanal atresia may be associated with various
other anomalies:

CHARGE syndrome (coloboma; heart disease; atresia
of the choanae; retarded growth, development and/or
central nervous system anomalies; genital hyperplasia;
ear anomalies or deafness).
Diagnosis

The clinical suspicion of choanal
atresia can be confirmed by
examination with a rigid or flexible
endoscope

The acute care of choanal atresia in asphyxia consists of
intubation followed by perforation of the atresia plate

The definitive surgical repair of bilateral choanal atresia is
performed during the first weeks or months of life.

Surgery for unilateral atresia can be postponed until
school age, when the anatomy of the region is more
similar to that encountered in adults

Incidence of dysraphias involving the anterior
skull base is approximately one in 20,000 to one in
40,000 births

Various manifestations that include:
1.
2.
3.
4.
Dorsal nasal fistulas
Dermoids
Frontonasal extracerebral gliomas
Frontonasal extracerebral cephaloceles
 A dorsal nasal fistula consists of a fistulous tract
that is lined by keratinized squamous epithelium
and forms a tiny opening on the dorsum or tip of
the nose

Fistulas that terminate blindly are usually
manifested clinically at an older age due to
inflammation around the fistulous opening.

If the fistula communicates with the
subarachnoid space, it can lead to severe
complications such as cerebrospinal fluid leakage,
meningitis, or brain abscess

The diagnosis is established by computed
tomography or magnetic resonance imaging.

Diagnostic catheterization or contrast injection is
contraindicated due to the risk of intracranial
complications.

Treatment consists of complete removal
of the fistulous tract

Cephaloceles are herniations of intracranial
contents through a bony defect in the skull

Most cephaloceles are congenital, but rare cases
are post-traumatic

Sincipital cephaloceles are located near the
glabella, forehead or orbit.

Basal cephaloceles are found mainly in the nasal
cavity or nasopharynx.
Presentation
Most are manifested
clinically during
childhood.
The sincipital forms
appear as:
a pulsating mass near
the glabella, often
associated with a
broad nasal dorsum
and hypertelorism

Basal forms present as :
an intranasal mass, typically with associated
nasal airway obstruction.
They closely resemble intranasal polyps and
should be considered in the differential diagnosis
of children with suspected nasal polyps, which are
rare in this age group

Computed tomography (CT) and magnetic
resonance imaging (MRI)

Always surgical and consists of removing the
cephalocele and repairing the dural defect